Medical History Form
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4BIRMINGHAM ALLERGY & ASTHMA SPECIALISTS, PC
HISTORY & PHYSICAL
NAME:________________________________________
TO BE COMPLETED BY PHYSICIAN
APPOINTMENT DATE:__________________________
DATE OF BIRTH:_______________________________
CHIEF COMPLAINT:
PRIMARY CARE PHYSICIAN: ___________________
REFERRED BY: ________________________________
TO BE COMPLETED BY PATIENT
Please describe in your own words the reason for this visit.
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
HISTORY OF PRESENT ILLNESS:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
CURRENT MEDICATIONS: Please list all
medications, both prescribed by a physician and
obtained without a prescription (over the counter), that
you are currently taking.
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
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Birmingham Allergy & Asthma Specialists, PC
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